by Brandy Brimhall, CPC, CMCO, CCCPC, CPCO, CPMA
August 19th, 2015
With the recent release of the 2015 OIG Work Plan, many providers and facilities are reviewing the content to learn which areas of interest pertaining to their specialty will be points of interest for federal auditing programs for the 2015 Fiscal Year. The information contained in this Work Plan addresses the achievements of the previous year's plan for efforts of fraud, waste, and abuse prevention, as well as the direction intended for the up and coming year.
As always, many specialties are addressed in this Work Plan and chiropractic is again an area of focus for the 2015 Fiscal Year. Note that the yearly OIG report, though it addresses government programs such as Medicare/Medicaid, the information provided within it serves also as a tool for private payers and non-government related programs alike. This means that the findings, successes and future strategies of the OIG helps private payers to improve and enforce their own investigative efforts to reduce fraud, waste, and abuse within their programs. That said, all providers should be aware of the findings and direction of the OIG as it is published for each new year.
In summary of the 2015 Work Plan, the priority interests in chiropractic claims include the following:
•Medicare Part B payments for non-covered services
Medicare strictly defines rules for establishing and supporting Medical Necessity (42 CFR § 410.21(b) and also clearly defines chiropractic maintenance therapy as not "reasonable or necessary" and is therefore deemed not payable (Medicare Benefit Policy Manual, Pub. No. 100-02, ch. 15, § 30.5B.)
Audit and recovery efforts in previous years have proven successful in revealing chiropractic claims that do not support medical necessity as defined by Medicare. As a result, continued efforts to this effect are part of the 2015 OIG strategy.
•Questionable billing for chiropractic services
For the chiropractic adjustment to be covered by Medicare, it is required that "a reasonable expectation of recovery or improvement of function" is clearly established (Medicare Benefit Policy Manual, Pub. No. 100 02 ch. 15 § 240.1.3). The OIG makes note of high claim error rates in chiropractic which is an excellent indicator that RAC, ZPIC, and other programs assigned with the role of investigating program integrity will strengthen in 2015. It is noted also in the 2015 Work Plan that not only is there interest in investigating fraud or abuse but also in documentation to ensure that patient records are meeting Medicare requirements.
•Provider Integrity for Medicare Advantage Plans (Medicare Part C)
Reviews indicate that medical record documentation does not always support the diagnoses submitted for processing. Due to this, medical necessity is not always clearly supported and therefore it has been determined that improper payments have been issued to providers due to inaccurate or inappropriate use of diagnoses. Further evaluation of provider documentation is of interest, due in part to this finding.
•Vulnerabilities to the Medicaid program
The OIG has plans for 2015 to address how states are working to implement required corrective actions, reduce vulnerabilities of fraud and abuse as well as over payments to providers. Recovery efforts and processes are intended to be addressed with all states to ensure compliance with Federal requirements and proper implementation of these audit, review, and integrity systems.
Additionally, a few other topics that are in the 2015 forecast to receive additional OIG attention include the following:
In addition to other efforts in place to prevent fraud and abuse, provider eligibility for CMS programs is another level that is being addressed. The OIG Work Plan notes that CMS is implementing new authorities that include; site visits, fingerprinting, background checks, as well as an automated provider screening process.
•Security of electronic data
•Use and exchange of health information technology
•Emergency preparedness and response efforts
These areas, among others noted in the official Work Plan, are compliance related efforts that are new to the OIG Work Plan. This alone should serve as encouragement for practices to begin to learn and implement a sound Compliance Plan.
As mentioned previously, the OIG Work Plan addresses projects and focal points for multiple specialties, states and program payers alike. This article serves as a summary for not only the OIG 2015 areas of interest that are specific to chiropractic but also those focal points that may pertain to chiropractic as well as many other provider types or related organizations that are involved in CMS programs.
For assistance or information, please contact ChiroCode. You may also reference the entire 2015 OIG Work Plan here: